Author: noorali

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Early Detection of Stroke Improves Outcome

Lincoln Memorial in Washington, D.C. (Dr. Noorali Bharwani)
Lincoln Memorial in Washington, D.C. (Dr. Noorali Bharwani)

“Advances in the management of stroke promise to significantly improve outcomes for patients,” says an article in the CMPA Perspective in their September 2015 newsletter. CMPA (Canadian Medical Protective Association) advises physicians on medico-legal issues.

The most important thing is prompt recognition of signs and symptoms of stroke. Often the benefits of these advances are best realized if stroke is promptly recognized and treated. The efficacy of thrombolysis (clot busting drug) is up to 4.5 hours from the onset of symptoms and studies have confirmed the importance of the time to treatment for positive outcome.

Ischemic stroke (stroke due to a blood clot) is a medical emergency. It requires fast and effective collaboration between a neurologist and radiologist.

Stroke is the second leading cause of death. Stroke affects people of all ages. The lifetime risk of overt stroke is estimated at one in four by age 80 years.

There are two types of stroke, either ischemic (in 85 per cent of cases) or hemorrhagic (in 15 per cent of cases). Hemorrhagic strokes are divided equally into intracerebral hemorrhage (bleeding in the brain) and atraumatic subarachnoid hemorrhage (bleeding in the lining of the brain).

The public can be taught to recognize and act upon stroke using the acronym FAST, for facial droop, arm drop, speech disturbance and time. There may be other symptoms too.

A review article in the Canadian Medical Association Journal (CMAJ September 8, 2015) says, “The most important historical feature of stroke is the suddenness of its onset. Identification of a stroke syndrome is relatively easy: sudden onset of acute neurologic symptoms, peaking within a few minutes, is deemed a stroke until proven otherwise.”

In a review of cases, CMPA found that the biggest issue was the difficulty of early diagnosis. Most patients first present in a hospital emergency. Some went to their family physicians or a walk-in clinic.

More than a quarter of the patients died. Another 40 per cent were left with permanent disability. That means about 70 per cent of the patients who have a stroke either died or became permanently disabled. That is not a very good outcome.

Research suggests that about 10 per cent of the cases are not diagnosed initially because the patient presents with atypical symptoms. In the cases reviewed by CMPA, the most common symptoms were headache, dizziness, nausea and vomiting.

A full clinical exam is important and patient should be observed. If symptoms deteriorate then further evaluation should be done. Special attention should be given to patients who have risk factors like smoking, obesity and hypertension.

Thorough clinical evaluation is important. You cannot solely rely on CT scan. In ischemic stroke CT scan is quite often normal in the first 24 hours. In case of subarachnoid hemorrhage the CT scan will be positive in the first six hours but this number drops to 85 per cent if the CT is done after six hours.

Rapid clinical diagnosis, urgent CT scan and urgent use of clot busting drug within 4.5 hours is critical in achieving positive outcome in ischemic stroke.

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Sibling Rivalry can be a Source of Anxiety for Parents

There is strength in unity. Boating in North Glenmore Park, Calgary. (Dr. Noorali Bharwani)
There is strength in unity. Boating in North Glenmore Park, Calgary. (Dr. Noorali Bharwani)

“Siblings that say they never fight are most definitely hiding something,” says novelist Lemony Snicket.

If you look at it in a positive way, sibling rivalry is a type of competition. It can be a healthy rivalry. If it goes in a negative way then rivalry creates animosity and nightmare for parents.

There are several factors involved in how the siblings bond. Siblings generally spend more time together during childhood than they do with parents. As they grow the relationship is often complicated and is influenced by factors such as parental treatment, birth order, personality, and people and experiences outside the family.

If the children are very close in age and of the same gender and/or where one or both children are intellectually gifted then the relationship can be complicated.

Listening to your children fight with each other can be frustrating. As parents what can you do to create harmony? Problem comes when parents start taking sides. Things become more difficult if you have more than two children.

So I did some reading to see what the experts have to say. Here is the summary:

  1. Accept the fact that if you have more than one child there is going to be sibling rivalry. If the rivalry is healthy then it creates healthy, smart, happy family.
  2. Parents should learn to know when and how to intervene when siblings have a conflict. Taking sides is totally unnecessary and can be counter productive. You cannot have one favourite child out of two or more children you have.
  3. Parents should remember sibling rivalry typically develops as siblings compete for their parents’ love and respect. That is natural part of growing up. Rivalry also depends on children’s age, sex and personality, the size of the family, whether it’s a blended family, and each child’s position in it.
  4. As children grow parents find out that each child has unique habits and needs although they have genes from the same parents. Learn to respect each child’s unique needs.
  5. Parents have a tendency to compare their children’s achievements and disappointments. Avoid comparisons. Comparing your children’s abilities can make them feel hurt and insecure. Each child is born with unique gifts. Parents should learn to understand this and nurture them.
  6. Parents should learn to listen to their children. They should encourage their children to talk to each other and learn to understand and appreciate each other’s successes and failures. Family dinners also provide opportunities for talking and listening.
  7. Never forget to compliment your children when they behave well, have success in their endeavors, are playing well together or working as a team. Encourage good behavior.
  8. Show your love. Spend time alone with each of your children. Do special activities with each child that reflects his or her interests. Remind your children that you are there for them and they can talk about anything with you.

I am sure there is more to parenting than just eight points mentioned here. I feel the most important point is to give each child unconditional love. They will never forget that. I am sure they will pass that unconditional love to their children.

Long live good parenting.

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Pregnancy and the Risk of Traffic Collision

Washington Monument at the National Mall in Washington, D.C. (Dr. Noorali Bharwani)
Washington Monument at the National Mall in Washington, D.C. (Dr. Noorali Bharwani)

The Canadian Medical Association Journal (CMAJ March 1, 2016) has awarded its top research honour to the authors of a study that showed women face an increased risk of serious car accidents during pregnancy.

Dr. Donald Redelmeier and his colleagues are the recipients of the Bruce Squires Award for their article “Pregnancy and the risk of a traffic crash,” which showed that pregnant drivers were 42 per cent more likely to have a serious collision that resulted in an emergency department visit. It generated the most public interest of any CMAJ research paper in 2015, says the CMAJ article.

Redelmeier’s team analyzed the health records of 507 262 Ontario women who gave birth between April 1, 2006 and March 31, 2011. The researchers found that the risk of a serious crash peaked in the fourth month of pregnancy, and was higher in the afternoon and in complicated traffic. It affected pregnant women regardless of their background, whether they had been pregnant before, or whether they were carrying a boy or a girl, says CMAJ article.

The authors concluded that pregnancy is associated with a substantial risk of a serious motor vehicle crash during the second trimester.

The World Health Organization classifies maternal deaths due to traffic crashes as coincidental and not related to the state of pregnancy. Others have argued that pregnancy is the root cause of such deaths, because pregnant women are more susceptible to crashes.

In 2014, CMAJ published a commentary (July 8, 2014) on Redelmeier’s research. The title of the commentary was “High risk of traffic crashes in pregnancy: Are there any explanations?” The commentary touched on several likely explanations. Here is the summary:

  1. Driving requires a high level of concentration and cognitive ability to maintain and complete a number of complex tasks. If there is any impairment in the driver’s cognitive ability, there may be an increased risk of a crash.
  2. The physiologic changes of pregnancy have been shown to increase fatigue and sleep deprivation in pregnant women.
  3. Prospective study using self-reported questionnaires showed that sleep length began to decrease during the second trimester and quality of sleep worsened during pregnancy.
  4. Maternal stress is also a common feature of pregnancy.
  5. Drivers who experience sleep deprivation, stress or fatigue will have an increased risk of a car crash.
  6. If busy urban areas are harder to navigate and require greater concentration in driving, then fatigue, tiredness and stress are likely to have a greater impact on the risk of a crash in urban areas.

There is no doubt studies have shown an increased risk of motor vehicle crashes among women in their second trimester of pregnancy.

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Are we doing too many colonoscopies? The new guidelines are here.

Dr. Noorali Bharwani demonstrating flexible sigmoidoscopy.
Dr. Noorali Bharwani demonstrating flexible sigmoidoscopy.

First, let us face the facts. Colorectal cancer is the third most commonly diagnosed cancer in Canada. It is the second leading cause of cancer death in men and the third in women. The lifetime probabilities of dying from colorectal cancer among men and women are three to four per cent.

What’s the best way to prevent colon and rectal cancer?

We have been doing colonoscopies just over 50 years. The technology is changing almost every year. The service is now available almost everywhere. There are more doctors doing colonoscopy. And people are getting the procedure done more often. The indications of doing the procedure are increasing everyday. The saying goes, “If you haven’t had a colonoscopy then you need one. If have had one then you need another one!” Is that the way to go?

Last time the guidelines for colonoscopy were updated was 2001. Now, in 2016, we have new guidelines from the Canadian Task Force on Preventive Health Care. The new guidelines state there is not enough evidence to justify colonoscopies as routine screening for colorectal cancer. Instead, patients should undergo fecal occult blood testing every two years, or flexible sigmoidoscopy every 10 years. Flexible sigmoidoscopy is a procedure in which a scope is inserted in the lower portion of the colon and rectum rather than the entire tract. I used to provide that service in my office.

It is sad to note that currently no provincial screening program includes flexible sigmoidoscopy.

It is important to remember that the guidelines apply to adults aged 50 to 74, who are asymptomatic and at low risk for colorectal cancer, meaning they have no prior history of the disease, no family history, no symptoms such as blood in the stool, or genetic predisposition. If they have any of these risk factors then they need a colonoscopy – full examination of the colon and rectum.

The task force hopes that ultimately, most Canadians will likely be screened using fecal occult blood tests, which look for microscopic specks of blood in the stool that could be a sign of cancer. If that is positive then a colonoscopy is indicated. If a flexible sigmoidoscopy (a 60-cm scope which examines the rectum and left colon) is positive for any abnormal findings then the person needs a colonoscopy.

To spread this message, we have to educate the public about the risk of the disease and the safety and importance of screening. Adults 75 and over should not be ignored. If they are in good health then they should discuss with their doctor and get into the screening program.

Colonoscopy is a great test but because waiting lists are long and the potential for side effects such as bleeding or intestinal perforation are greater than they are for other tests, the guidelines recommend against using colonoscopies as a routine screening tool in asymptomatic low-risk adult.

The old guidelines (2001) recommended annual or biennial faecal occult blood test (FOBT) and flexible sigmoidoscopy every five years in asymptomatic people older than 50 years. The guideline did not recommend whether these screening modalities should be used alone or in combination or whether to include or exclude colonoscopy as an initial screening test for colorectal cancer. And provincial screening programs do not include flexible sigmoidoscopy as one of their screening options. This should change.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!